Les Form Dwc-3 - Request For Wage Loss/temporary Partial Benefits 1991 Page 2

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NAME
SOCIAL SECURITY NUMBER
WORK SEARCH REPORT
DURING THE TWO WEEK PERIOD CLAIMED, I HAVE ATTEMPTED TO FIND EMPLOYMENT WITHIN MY PHYSICAL AND VOCATIONAL CAPABILITIES AT EACH BUSINESS, EMPLOYMENT
AGENCY AND JOB SERVICE OF FLORIDA LOCATION LISTED BELOW.
DATE
JOB
CONTACT
NAME, ADDRESS AND TELEPHONE
APPLICATION
RESULT OF
APPLIED FOR
PERSON
NUMBER OF COMPANY
FILED
CONTACT
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO

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